Rewriting the sicknote story

A worker with a progressively worsening record of sickness absence has, yet again, been off work for more than a week, and your colleagues in OH, the HR manager, and the employee’s line manager are all becoming concerned.

But all is not lost – the employee’s ‘fit note’ has also arrived from their GP, outlining in detail the sorts of work duties the employee is fit to carry out, recommending some adjustments to the working environment, and outlining a possible timeframe for rehabilitation to full fitness.

Sounds fanciful, doesn’t it? But it is an option being looked at closely by a government keen to reform how staff, and particularly those on incapacity benefit, are signed off work by GPs.

Working party

The Department for Work and Pensions has set up a working party to look at redesigning the Med 3 sicknote and, while the details are as yet sketchy, it is thought that trying to change it from a ‘sicknote’ to a ‘fit note ‘ is high on the agenda.

If so, this would tally with a recent proposal put forward by Dr Mike Goldsmith, chairman of the Commercial Occupational Health Providers’ Association (Cohpa). He believes the Med 3 should be scrapped altogether, and replaced with an ‘absence advice note’, in which GPs – for a fee of perhaps £10 to £20 – would outline to employers a patient’s ability to return to work.

Certainly reform, or at the very least, a redesign of the Med 3, is long overdue. It is probably the only NHS form that NHS founder Aneurin Bevan would still recognise today. Employers still rely heavily on it when it comes to budgeting and managing their sick pay processes.

Yet the question of what role GPs should play in managing workplace health is becoming an increasingly pressing one for employers – particularly those who see the GP as the weakest link in the chain.

As Dr Geoff Davies, consultant occupational health physician and managing director of OH provider Adastral Health puts it: “Most GPs want to stop writing sicknotes, but some still like the power it gives them. You get doctors signing back teachers, for example, for two days before the summer holiday, and then signing them off again in September. The deciding issue with some GPs is power.”

Davies outlined his views at November’s In Health and In Work conference, where alternatives to GP sicknote certification were discussed. He made the frustration many employers felt at the pivotal role GPs still hold within sickness certification abundantly clear.

“It is a small minority, but it is damaging, because everyone talks about these cases,” he says. “Most employers want to be fair and supportive. Yes, there are a few rogues, but most of them simply want to manage their cases, and the Med 3 is a barrier. They feel they cannot question the GP’s opinion.

“It is frustrating for HR because they cannot make a plan, and it is difficult for OH practitioners to countermand the GP view, even if it is illogical. It is difficult to say someone is not going to end up in a wheelchair because they go back to work with back pain,” he suggests.

Laying blame

This is, of course, an argument that has been batted back and forth between employers and the medical profession for some time.

In November, Dr Peter Holden, GP and chairman of the professional fees committee at the British Medical Association (BMA), told Occupational Health’s sister title, Personnel Today, that it was all the fault of employers for failing to tackle absence properly. “Firms want to [pass] responsibility for this topic to GPs. Talking to employees about absence is difficult, and going the sicknote route is an easy cop-out for employers,” he said.

Yet what also became abundantly clear at the In Health and In Work conference, which unveiled the results of year-longpilots into some OH-led alternatives, is that employees and even employers set great store by the Med 3 and the GP’s verdict, however flawed or illogical. Like it or lump it, for the time being at least, or unless there is a huge cultural or attitudinal shift, GPs are stuck with the Med 3.

This loyalty to the status quo and suspicion of what change entails was one of the key reasons for the disappointing outcome of the sicknote alternative pilots, as reported in December’s Occupational Health. Through a combination of union resistance, lack of managerial commitment and deep employee scepticism, the pilots left the profession none the wiser as to whether OH has a role to play in taking on some of the burden of sicknote certification.

As professor Jeremy Dale, director of the Centre of Primary Health Care Studies at Warwick Medical School, who led the evaluation of the pilots, put it: “What became very clear was the entrenched value that not only employees, but employers place on the Med 3. They were happy to participate in the pilot, but they were much more wary about saying to employees that they did not need a Med 3.”

Re-education

So, what is to be done? How can the GP’s role in relation to workplace health be developed? The sicknote alternatives pilots did, at the very least, reveal the scale of the difficulties and the amount of re-education that will be needed, says Dr Simon Fradd, a GP and a keen advocate of reforming the Med 3.

“At the moment, we basically have a system of sicknote on demand, and that does not help anybody,” he concludes. “It does not rehabilitate people back into work, and does not make people – particularly young people – aware of the fact that if they build up a poor health record, it can damage their career prospects.”

But ideas such as that proposed by Goldsmith will, he suggests, be unworkable. Partly, this is because of money – in that employers, particularly smaller ones, will be unlikely to want to stump up for such reports. It is also partly because GPs already claim the burden of sicknotes is too much as it is, and so simply writing bigger, more complex reports is hardly the answer. And finally, it is because GPs are probably not the best people to ask about a patient’s fitness to work in the first place.

“GPs are not OH clinicians,” Fradd points out. “We do not need a doctor-led service. It needs to be a well-trained nurse who is versed in OH, and we also need to be making the career more attractive and pay enough. OH is a very small speciality, so there are not the resources thrown at it that there should be.”

It may not even be that the Med 3 needs to be redesigned, but a question of better training and education, argues Dr Sayeed Khan, chief medical adviser at the engineering and manufacturers’ association EEF.

The form already has a ‘remarks’ section, where a GP could suggest modifications to a workplace’s environment or practices that might help get a patient get back to work.

“In many organisations, someone could at the very least just come in and answer the phone. That’s much better than just having them sitting at home,” he says. “There are very few organisations that say you cannot come in unless you are 100% fit.”

Work is already afoot at the Royal College of General Practitioners to raise the profile of OH training among new and existing GPs. The Department for Work and Pensions (DWP) has agreed to fund educational workshops for up to 50 GPs at a time around the country which will get under way this summer.

These are intended to explain to GPs some of the key issues to think about and be aware of in terms of health at work when seeing patients.

“It is going to be kept pretty basic – fitness to work, rehabilitation, workplace adjustments, certification and so on,” says Khan. “It is about GPs giving proper advice and support. They may find out it has nothing to do with work, but they need to be looking at health at work – they need to be putting things in context.”

Specialised area

The difficulty with simply giving GPs a bit of extra training is that OH is now a pretty specialised area, so it is a moot point whether it will make any difference, warns Dudley Lusted, head of corporate healthcare development at health insurer AXA.

“The fact that someone has an interest in OH is not good enough,” he says. “Would you like to have surgery done by a GP with an interest in open heart surgery?

“There should be a minimum degree that someone needs to demonstrate before they can say they are an OH doctor.”

Another issue is that, even with their new lucrative contracts, there is a shortage of GPs around the country, with retention, burn-out and early retirement still key issues facing that profession. How, in that context, it will be possible to extend some GPs into an OH physician-style role, is hard to gauge.

Manage effectively

The idea put forward by Goldsmith might well be a goer, although £20 is probably unrealistically low, Lusted argues. “Let’s stop worrying about the Med 3 and get a proper report from a doctor asking the questions that managers and personnel want to get answered,” he suggests. “It needs to be about functionality and adjustment, rather than simply fitness to work.”

The key message for employers, Lusted says, is not to sit back and wait for government, the medical profession, OH or anyone else to come up with an answer, but simply to get out and manage absence more effectively and proactively themselves.

Employers need to recognise they may be able to question GPs’ decisions and that, if necessary, as long as they have a watertight case, there is nothing to stop them disciplining a malingering worker simply because they are clutching a Med 3.

Some form of OH expertise attached to a primary care system could be one way forward but not, he stresses, first-day absence schemes or nurse-led call centres, which can sometimes do more harm than good.

“You should only be worrying about absence when it is frequent. It can be insulting to a loyal worker with a good attendance record who takes their first day off in months or even years,” he says.

But, in reality, will this debate really change anything? At one level, with the NHS facing a cash crisis and a government this year in transition at the top, the answer is probably no. Certainly, too, for GPs, there are many other issues that are either equally or even more pressing than the reform of sicknote certification.

Yet, with much of the political energy on sickness absence now focused on getting incapacity benefit claimants back into the workplace – of which sicknote certification is a key part – and the DWP actively working on redesigning the Med 3, there may yet be progress made.

But after the disappointment of the sick­note alternatives pilot schemes and the revelation of the mountain to climb, Fradd, at least, is sceptical.

“The government, I suspect, will not do anything, and I think it is very, very sad,” he says. “It is letting down patients, employers and the medical profession.”

CASE STUDY: BRADFORD-ON-AVON OH SERVICES

The notion of OH working within a primary care setting, reaching out to employers and acting as a conduit between employer and GP is one that is becoming increasingly attractive to many in the profession.

One area where such a model has proved a success is in Bradford-on-Avon, where OH nurses have been using a GP surgery to bring workplace health advice and support to small businesses in Wiltshire since 1999.

It grew out of GP-based work being done at the Avon Rubber factory, a large local employer. Over time, this has evolved into a nurse-led service attached to the GP practice that now works with a wide range of local organisations, including vets, a safari park, a cement works and educational institutions.

Services offered include health surveillance, noise conservation, case management and workstation assessments, as well as in-house OH nursing and direct access to physiotherapy and counselling.

“What we have created is a nurse-led service, led by nurses, with nurses,” explains OH specialist practitioner Helen Clinkard. “We have moved from a medical model to a health model.”

Half the challenge when it comes to targeting small- to medium-sized enterprises (SMEs) is that they often do not know what they want themselves, explains Clinkard, who was speaking at the In Health and In Work conference.

“Often they just want first aid, not OH,” Clinkard says. “But GPs are small businesses themselves, so they understand the pressures that many SMEs are under, because they are under them too.”